Your Rights and Responsibilities as a Member of our Plan
Introduction to Your Rights and Protections
Since you have Medicare, you have certain rights to help protect you. In this section, we explain your Medicare rights and protections as a member of our Plan and we explain what you can do if you think you are being treated unfairly or your rights are not being respected.
We must provide information in a way that works for you (in languages other than English, in Braille, in large print, or other alternate formats, etc.)
Tenemos que darle la información de una manera que funcione para usted (en idiomas distintos del Inglés, en el braille, en letra grande o en otros formatos alternativos, etc.)
To get information from us in a way that works for you, please call Member Services.
Our plan has people and free interpreter services available to answer questions from disabled and non-English speaking members. We can also give you information in Braille, in large print, or other alternate formats at no cost if you need it. We are required to give you information about the plan’s benefits in a format that is accessible and appropriate for you. To get information from us in a way that works for you, please call Member Services or contact Optimum HealthCare Civil Rights Coordinator.
If you have any trouble getting information from our plan in a format that is accessible and appropriate for you, please call to file a grievance with the plan by calling plan 1-866-245-5360 (TTY: 711). You may also file a complaint with Medicare by calling 1-800-MEDICARE (1-800-633-4227) or directly with the Office of Civil Rights. You may contact Member Services for additional information.
Para obtener información de nosotros de una manera que funcione para usted, por favor llame a nuestro Departamento de Servicios al Miembro.
Nuestro plan cuenta con personas y servicios de traducción disponibles para responder a las preguntas de los miembros de habla discapacitados y no inglés. También podemos darle información en Braille, en letra grande, u otros formatos alternativos sin costo si lo necesita. Tenemos que brindarle información sobre los beneficios del plan en un formato que sea accesible y apropiado para usted. Para obtener información de nosotros de una manera que funcione para usted, llame a Servicios para Miembros o comuníquese con el Coordinador de Derechos Civiles de Optimum HealthCare.
Si tiene alguna dificultad para obtener información de nuestro plan en un formato que sea accesible y adecuada para usted, por favor llame a presentar una queja con el Plan llamando al 1-866-245-5360 (TTY: 711). También puede presentar una queja ante Medicare llamando al 1-800-MEDICARE (1-800-633-4227) o directamente a la Oficina de Derechos Civiles. Puede comunicarse con Servicios para Miembros para obtener información adicional.
We must treat you with fairness and respect at all times
Our plan must obey laws that protect you from discrimination or unfair treatment. We do not discriminate based on a person’s race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location within the service area.
If you want more information or have concerns about discrimination or unfair treatment, please call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019 (TTY 1-800-537-7697) or your local Office for Civil Rights.
If you have a disability and need help with access to care, please call Member Services. If you have a complaint, such as a problem with wheelchair access, Member Services can help.
We must ensure that you get timely access to your covered services and drugs
As a member of our plan, you have the right to choose a primary care provider (PCP) in the plan’s network to provide and arrange for your covered services. Call Member Services to learn which doctors are accepting new patients. You also have the right to go to a women’s health specialist (such as a gynecologist) without a referral.
As a plan member, you have the right to get appointments and covered services from the plan’s network of providers within a reasonable amount of time. This includes the right to get timely services from specialists when you need that care. You also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays. For medical assistance or care after normal business hours, please contact your PCP for availability of after hour services or visit your nearest urgent care facility.
If you think that you are not getting your medical care or Part D drugs within a reasonable amount of time, please call Member Services.
We must protect the privacy of your personal health information
Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.
Your “personal health information” includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information.
The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We give you a written notice, called a “Notice of Privacy Practice,” that tells about these rights and explains how we protect the privacy of your health information.
How do we protect the privacy of your health information?
We make sure that unauthorized people don’t see or change your records.
In most situations, if we give your health information to anyone who isn’t providing your care or paying for your care, we are required to get written permission from you first. Written permission can be given by you or by someone you have given legal power to make decisions for you.
There are certain exceptions that do not require us to get your written permission first. These exceptions are allowed or required by law.
- For example, we are required to release health information to government agencies that are checking on quality of care.
- Because you are a member of our plan through Medicare, we are required to give Medicare your health information including information about your Part D prescription drugs. If Medicare releases your information for research or other uses, this will be done according to Federal statutes and regulations.
You can see the information in your records and know how it has been shared with others
You have the right to look at your medical records held at the plan, and to get a copy of your records. We are allowed to charge you a fee for making copies. You also have the right to ask us to make additions or corrections to your medical records. If you ask us to do this, we will work with your healthcare provider to decide whether the changes should be made.
You have the right to know how your health information has been shared with others for any purposes that are not routine.
If you have questions or concerns about the privacy of your personal health information, please call Member Services.
We must give you information about the plan, its network of providers, and your covered services
You have the right to get several kinds of information from us. You have the right to get information from us in a way that works for you. This includes getting the information in languages other than English and in large print or other alternate formats.
If you want any of the following kinds of information, please call Member Services:
Information about our plan
This includes, for example, information about the plan’s financial condition. It also includes information about the number of appeals made by members and the plan’s performance ratings, including how it has been rated by plan members and how it compares to other Medicare health plans.
Information about our network providers including our network pharmacies
- For example, you have the right to get information from us about the qualifications of the providers and pharmacies in our network and how we pay the providers in our network.
- For a list of the providers and pharmacies in the plan’s network, see the Provider and Pharmacy Directory.
- For more detailed information about our providers or pharmacies, you can call Member Services or visit our website at www.youroptimumhealthcare.com.
Information about your coverage and the rules you must follow when using your coverage
Chapters 3 and 4 of your Evidence of Coverage (EOC) explain what medical services are covered for you, any restrictions to your coverage, and what rules you must follow to get your covered medical services.
To get the details on your Part D prescription drug coverage, see Chapters 5 and 6 of your EOC plus the plan’s List of Covered Drugs (Formulary). These chapters, together with the List of Covered Drugs (Formulary), tell you what drugs are covered and explain the rules you must follow and the restrictions to your coverage for certain drugs.
If you have questions about the rules or restrictions, please call Member Services.
Information about why something is not covered and what you can do about it
If a medical service or Part D drug is not covered for you, or if your coverage is restricted in some way, you can ask us for a written explanation. You have the right to this explanation even if you received the medical service or drug from an out-of-network provider or pharmacy.
If you are not happy or if you disagree with a decision we make about what medical care or Part D drug is covered for you, you have the right to ask us to change the decision. You can ask us to change the decision by making an appeal. For details on what to do if something is not covered for you in the way you think it should be covered, see your EOC. It gives you the details about how to make an appeal if you want us to change our decision. Chapter 9 of your EOC also tells you about how to make a complaint about quality of care, waiting times, and other concerns.
If you want to ask our plan to pay our share of a bill you have received for medical care or a Part D prescription drug, see Chapter 7 in your EOC.
The Plan is always looking for ways to give our members the best care possible. We do this by reviewing new technology, which could be for medical procedures, drugs, or devices. To be considered, the new technology must meet strict government rules. Our Medical Staff research these new treatments through review of the latest scientific articles and by talking with specialists in that area. If approved, the new technology is added as a covered service.
You have the right to know your treatment options and participate in decisions about your health care
You have the right to get full information from your doctors and other health care providers when you go for medical care. Your providers must explain your medical condition and your treatment choices in a way that you can understand.
You also have the right to participate fully in decisions about your health care. To help you make decisions with your doctors about what treatment is best for you; your rights include the following:
- To know about all of your choices. This means that you have the right to be told about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan. It also includes being told about programs our plan offers to help members manage their medications and use drugs safely.
- To know about the risks. You have the right to be told about any risks involved in your care. You must be told in advance if any proposed medical care or treatment is part of a research experiment. You always have the choice to refuse any experimental treatments.
- The right to say “no.” You have the right to refuse any recommended treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. You also have the right to stop taking your medication. Of course, if you refuse treatment or stop taking medication, you accept full responsibility for what happens to your body as a result.
- To receive an explanation if you are denied coverage for care.You have the right to receive an explanation from us if a provider has denied care that you believe you should receive. To receive this explanation, you will need to ask us for a coverage decision. Chapter 9 of your EOC tells how to ask the plan for a coverage decision.
You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself
Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in this situation. This means that, if you want to, you can:
- Fill out a written form to give someone the legal authority to make medical decisions for you if you ever become unable to make decisions for yourself.
- Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself.
The legal documents that you can use to give your directions in advance in these situations are called “advance directives.” There are different types of advance directives and different names for them. Documents called “living will” and “power of attorney for health care” are examples of advance directives.
If you want to use an “advance directive” to give your instructions, here is what to do:
- Get the form. If you want to have an advance directive, you can get a form from your lawyer, from a social worker, or from some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare.
- Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it.
- Give copies to appropriate people. You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you can’t. You may want to give copies to close friends or family members as well. Be sure to keep a copy at home.
If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital.
- If you are admitted to the hospital, they will ask you whether you have signed an advance directive form and whether you have it with you.
- If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one.
Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive.
What if your instructions are not followed?
If you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with the Florida Quality Improvement Organization called KEPRO at 5201 W. Kennedy Blvd., Ste. 900, Tampa, FL 33609, or by phone at 1-844-455-8708.
You have the right to make complaints and to ask us to reconsider decisions we have made
If you have any problems or concerns about your covered services or care, Chapter 9 of your EOC tells what you can do. It gives the details about how to deal with all types of problems and complaints. What you need to do to follow up on a problem or concern depends on the situation. You might need to ask our plan to make a coverage decision for you, make an appeal to us to change a coverage decision, or make a complaint. Whatever you do – ask for a coverage decision, make an appeal, or make a complaint – we are required to treat you fairly.
You have the right to get a summary of information about the appeals and complaints that other members have filed against our plan in the past. To get this information, please call Member Services.
What can you do if you believe you are being treated unfairly or your rights are not being respected?
If it is about discrimination, call the Office for Civil Rights
If you believe you have been treated unfairly or your rights have not been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019, or TTY/TDD 1-800-537-7697, or call your local Office for Civil Rights.
Is it about something else?
If you believe you have been treated unfairly or your rights have not been respected, and it’s not about discrimination, you can get help dealing with the problem you are having:
- You can call Member Services
- You can call the State Health Insurance Assistance Program.
- Or, you can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048.
- You can visit the Medicare Web site to read or download the publication “Your Medicare Rights & Protections.” The publication is available at: https://www.medicare.gov/Pubs/pdf/10050-Medicare-and-You.pdf.
What are your responsibilities?
Things you need to do as a member of the plan are listed below. If you have any questions, please call Member Services. We’re here to help.
Get familiar with your covered services and the rules you must follow to get these covered services. Use your Evidence of Coverage booklet to learn what is covered for you and the rules you need to follow to get your covered services.
- Chapters 3 and 4 give the details about your medical services, including what is covered, what is not covered, rules to follow, and what you pay.
- Chapters 5 and 6 give the details about your coverage for Part D prescription drugs.
If you have any other health insurance coverage or prescription drug coverage in addition to our plan, you are required to tell us. Please call Member Services to let us know.
- We are required to follow rules set by Medicare to make sure that you are using all of your coverage in combination when you get your covered services from our plan. This is called “coordination of benefits” because it involves coordinating the health and drug benefits you get from our plan with any other health and drug benefits available to you. We’ll help you coordinate your benefits.
Tell your doctor and other health care providers that you are enrolled in our plan. Show your plan membership card whenever you get your medical care or Part D prescription drugs.
Help your doctors and other providers help you by giving them information, asking questions, and following through on your care.
- To help your doctors and other health providers give you the best care, learn as much as you are able to about your health problems and give them the information they need about you and your health. Follow the treatment plans and instructions that you and your doctors agree upon.
- Make sure your doctors know all of the drugs you are taking, including over-the counter drugs, vitamins, and supplements.
- If you have any questions, be sure to ask. Your doctors and other health care providers are supposed to explain things in a way you can understand. If you ask a question and you don’t understand the answer you are given, ask again.
Be considerate. We expect all our members to respect the rights of other patients. We also expect you to act in a way that helps the smooth running of your doctor’s office, hospitals, and other offices.
Pay what you owe. As a plan member, you are responsible for these payments:
- In order to be eligible for our plan, you must have Medicare Part A and Medicare Part B. For that reason, some plan members must pay a premium for Medicare Part A and most plan members must pay a premium for Medicare Part B to remain a member of the plan.
- For most of your medical services or drugs covered by the plan, you must pay your share of the cost when you get the service or drug. This will be a copayment (a fixed amount) or coinsurance (a percentage of the total cost). Chapter 4 of your EOC tells what you must pay for your medical services. Chapter 6 of your EOC tells what you must pay for your Part D prescription drugs.
- If you get any medical services or drugs that are not covered by our plan or by other insurance you may have, you must pay the full cost.
- If you disagree with our decision to deny coverage for a service or drug, you can make an appeal.
- If you are required to pay the extra amount for Part D because of your yearly income, you must pay the extra amount directly to the government to remain a member of the plan.
Tell us if you move. If you are going to move, it’s important to tell us right away. Call Member Services.
If you move outside of our plan service area, you cannot remain a member of our plan. We can help you figure out whether you are moving outside our service area. If you are leaving our service area, you will have a Special Enrollment Period when you can join any Medicare plan available in your new area. We can let you know if we have a plan in your new area.
- If you move within our service area, we still need to know so we can keep your membership record up to date and know how to contact you.
- If you move, it is also important to tell Social Security (or the Railroad Retirement Board).
Call Member Services for help if you have questions or concerns. We also welcome any suggestions you may have for improving our plan.
Last updated 10/01/2019